Doctor Name: _____________________________________ Date: _________________

Signature:_________________________________________________________________

License #: ___________________________ Phone: ( ) ______-_________________ Pre-ScheduledCity: _______________ State: ______ Zip: _______ Due Date: ____________________

Email: _________________________________ Preferred Communication: Email Phone

Patient Name: ________________________________________

Male Female Age: ____________

Adjacent Restorations Present Yes ___ No ___

Adjacent Tooth #’s Restored: _______________

Restorative Material Used: __________________

Pre-Op Shade: ________________ Requested Shade: ________________

Prep Shade: ________________

All teeth same Pt. Bleaching color and value

Gradient of color Occl. Stain - - - - - - - - - - - - - - - - - - - - - - - - Shade Diagram

Technicians Preference Y___ N____Metal Ceramic (PFM) Tooth #’s:_________________ Alloy Selection: High Noble White Yellow Noble White Metal-Ceramic Junction: ________ mm Metal Lingual Collar Only 3600 Metal Margin Porcelain Butt Margin: Y___ N___All Ceramic Tooth #’s: ________________ Empress E-Max Full Contour Zirconia Layered Zirconia Enamic FeldspathicFull Cast Crown/Onlay Tooth #’s: ________________

Implants placed by:

_________________________________________________Implant Brand: ___________________Implant Sizes: ____________________Implant Site #’s: ____________________Abutment PreferredTechnicians Preference Y___ N___USE OEM PARTS ONLY Y___ N____Stock: Titanium ___ Zirconia ___Custom: Cast ____ Titanium _____ Zirconia ___ Milled: Titanium ____ Shaded Titanium____Hybrid: Pressed with Ti Interface _____ Milled Zirconia with Ti Interface_____ One Piece Screw Retained _______

___ Make Custom Incisal Guide Table From: Pre_Op Casts Provisional Casts___ Develop Anterior Guidance (Cuspid)___ Develop Group Function___ Open Vertical Dimension by ______ mm

IF NOT ENOUGH RESTORATIVE ROOM___ Adjust Opposing Teeth ___ Adjust Preparation

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Materials Sent: Impression(s) Bite Record Study Models Opposing Model Shade Tab Photos / Card E-mail X-rays Dicom Data Implant Analog Implant Abutment(s) Intra – Oral ScanScan Bodies Used: _______________________________________________Lab Please Call to Discuss Please SendOverall Case Materials Esthetics Occlusion Boxes PrescriptionsOther: ________________________________________

Diagnostic Wax-Up Total # Units: ________________ Veneer Teeth #’s: ____________ Crown Teeth #’s: _____________ Onlay-Veneer #’s: ____________ Posterior-Teeth #’s: _____________Duplicate Silicone Index CopyplastProvisional Restorations Total # Units: ________________ Crown Tooth #’s: _____________Anterior Restorations Total # Units: ________________ Layered Tooth #’s: ____________ Stained Only Tooth #’s: _____________Posterior Restorations Total # Units: ______________ Layered Tooth #’s: __________ Stained Only Tooth #’s: ____________ Bridge Pontic Design Ovate Adjust Ridge Accordingly Ridge Lap No Ridge Adjustments

Excellence in Dental Prosthetics ™

Case Notes:

440-835-2541 24600 Detroit Rd. Suite 201, Westlake, Oh 44145

Send Photos to: photos@precisiondentalarts.com

Lab use only: Alloy_______ Weight_____ dwt Ingot_____ CAM_____ Pre-Scheduled Yes___ No____ Waranteed Yes___ No____ Code_______ YZ_______ 2 0 _________

Abutment Margin Design

Facial

Lingual

Mesial

Distal

Full Contour

Moderate Displacement

No Tissue Displacement

Abutment SurfaceMicro – Etched ___ Polished ___

Margin Type Shoulder ____ Chamfer _____

Depth _______ mm

Depth

Emergence

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